Sports Medicine: “Keep Your Eye on the Ball” Zach Stinson, M.D. Department of Orthopaedic Surgery and Sports Medicine FACULTY DISCLOSURE I have no relevant financial relationships with industry to disclose. -and- I will not discuss off label use and/or investigational use in my presentation. Topics ▪ Shoulder ▪ Wrist, forearm and elbow ▪ Hand ▪ Knee ▪ Foot/Ankle Shoulder Injuries ▪ Shoulder Dislocation ▪ Acromioclavicular Sprains or “Separated Shoulder” ▪ Clavicle Fractures ▪ Sternoclavicular Dislocation Shoulder Dislocation ▪ TUBS – Traumatic, unilateral, Bankart, surgery ▪ AMBRI – Atraumatic, multidirectional, bilateral, rehab, inferior capsular shift Evaluation and Management ▪ NV Status before and after reduction – 13% incidence of a neurologic injury ▪ Quality AP and Axillary Lateral Radiographs ▪ Patient must be relaxed for successful reduction ▪ Full time sling use/immobilization for 3-4 weeks ▪ Consider MRI Reduction Techniques Clavicle Fractures ▪ Fall directly onto shoulder or outstretched hand ▪ Obvious deformity ▪ Evaluate skin – Tenting or open wounds ▪ NV Status ▪ Radiographs – AP and 45 degree cephalic tilt Clavicle Fractures ▪ Most can be treated with sling immobilization – 3-4 weeks – Visible bone healing expected by 6-8 weeks ▪ Surgery occasionally indicated – No clear evidence in children that surgery is ever indicated over nonoperative treatment for any closed clavicle fracture type Clavicle Fractures ▪ Sling +/- Swathe (Shoulder Immobilizer) preferred over figure-of-8 brace – 26% of patients treated with figure-of-8 were dissatisfied vs. 7% treated with simple sling – Identical functional and cosmetic outcomes Andersen, K. et al. Acta Orthop Scand, 1987 AC “Separations” Sternoclavicular Dislocation ▪ Rare injury requiring high index of suspicion ▪ Pain more medial ▪ Displacement may occur through physis ▪ May have dyspnea or dysphagia ▪ Possible NV compromise from mediastinal compression ▪ Imaging – Serendipity - 40 degree caudocephalic tilt over the SCJ – CT scan ideal Wrist, Forearm and Elbow ▪ “FOOSH” Injuries ▪ Distal radius fracture most common ▪ Easy to miss nondisplaced distal radial physeal injury – Salter Harris I ▪ Examine entire extremity ▪ Thorough neurovascular exam ▪ Imaging with AP/lateral radiographs that include entire forearm ▪ Splint and follow-up unless open, NV compromise or unstable fracture pattern Elbow Dislocation ▪ Complete elbow dislocation – Often associated with incarcerated medial epicondyle fracture – Should be referred for urgent reduction ▪ Radiocapitellar dislocation – Associated with proximal ulna fracture – Monteggia fracture – Needs urgent management Hand and Carpus Injuries ▪ “Jammed” Fingers – Often results in avulsion fractures or angulated physeal injuries of the phalanges – Assess for rotational/angular deformity – Radiographs of isolated digit ideal – Closed reduction with digital block – Ulnar/Radial gutter splinting or thumb spica splint followed by buddy taping – Buddy taping sufficient for avulsion fractures Hand and Carpus Injuries ▪ Finger Dislocations – Obvious deformity – Obtain radiographs before and after reduction, if possible – Longitudinal traction with gentle manipulation – Open injuries or unstable/difficult to reduce need urgent referral – Buddy tape if simple, stable reduction or dorsal blocking splint if associated fracture Hand and Carpus Injuries ▪ Metacarpal fractures – Most can be treated with splint immobilization extended to finger tips – Keep wrist extended and digits flexed at MCP joints Hand and Carpus Injuries ▪ Scaphoid fracture – “FOOSH” Injury – Older Adolescent Child – Snuffbox Tenderness – Focused wrist radiographs – Thumb Spica Splint – Close follow-up – Commonly missed on imaging Knee Injuries ▪ Fractures ▪ Patella Dislocation ▪ Ligament Sprains/Tears ▪ Articular Cartilage ▪ Meniscus Tears General Considerations ▪ Knee effusion with associated trauma very sensitive for intra-articular injury ▪ Ideal radiographs include AP, Lateral and Sunrise ▪ Knee immobilizer and protected weight-bearing with close follow-up – With the exception of displaced fractures, compartment syndrome or NV compromise ▪ Always examine for possible hip pathology with simple ROM exam, if unclear – SCFE commonly has referred pain to the knee Distal Femur Fractures ▪ High risk of physeal arrest ▪ Mechanism – High-velocity trauma in younger juvenile patients – Low-energy sports injuries, usually hyperextension and valgus, in adolescents – Similar mechanism to collateral ligament sprains Distal Femur Fractures ▪ Plain radiographs may appear innocuous – Oblique Xray, contralateral films or consider MRI/CT ▪ Majority are Salter-Harris II fractures (54%) Proximal Tibia Physeal Fractures ▪ Uncommon injury – Metaphyseal attachment of ligaments ▪ Popliteal artery tethered to posterior tibia just below physis – Use abundance of caution and treat like a knee dislocation – NV injuries in 14% of cases – May auto-reduce to innocuous position ▪ Management is similar to distal femur fractures Management ▪ Nondisplaced fractures – Long leg splint or knee immobilizer – Close follow-up – MRI may be needed to confirm diagnosis ▪ Displaced fractures – Stabilize in long leg splint – Require urgent evaluation for reduction and stabilization Tibial Tubercle Fractures ▪ Non-contact – Violent contraction of the quadriceps ▪ Occur near end of growth ▪ Thought to be part of a spectrum of Osgood-Schlatter disease ▪ Pain with attempted knee extension against gravity ▪ Risk of anterior compartment syndrome – Injury to the anterior tibial recurrent Ogden Classification artery Management ▪ Stabilize in splint or knee immobilizer ▪ Most require operative treatment ▪ Anterior compartment fasciotomy may be indicated ▪ Immobilize for 4-6 weeks ▪ Return to sports requires 3 to 5 months ▪ Growth issues not common Patellar Dislocation ▪ Most common acute knee injury in adolescent athletes ▪ Non-contact injury produced by valgus and internal rotation of a planted leg ▪ Patient may self-describe the dislocation and subsequent reduction ▪ Multiple factors direct management – Anatomic variations, generalized ligamentous laxity, recurrent dislocations, presence of loose body 27 Evaluation ▪ Hemarthrosis, medial tenderness, possible VMO retraction ▪ If not reduced on presentation, gentle knee extension with medial force to achieve reduction • Consider positioning prone to relax hamstrings ▪ Plain X-rays – AP, lateral and merchant/sunrise views • Consider full-length radiographs ▪ MRI • Osteochondral injury or loose bodies • MPFL disruption and VMO retraction 28 Management ▪ Controversial ▪ Non-operative treatment generally preferred for first- time dislocation with no osteochondral loose body • Short period of immobilization and WBATwith early aggressive rehabilitation focused on VMO and core strengthening ▪ Surgical treatment indicated when loose body present or history of multiple dislocations 29 Pediatric ACL Tears ▪ Incidence in Children is Increasing – 18.9% increase in injury rate and 27.6% increase in rate of ACL reconstructions from 2007 to 2011 (Werner et al. JPO 2015) – Increased single sport specialization, higher level of intensity, increased awareness ▪ Male football players and female soccer players at highest risk ▪ Females are at 2-8 times greater risk Evaluation ▪ Noncontact injury ▪ May report a “pop” and 70% have an effusion ▪ Physical exam often limited in young, anxious patient – Lachman exam most sensitive test ▪ Orthogonal knee radiographs and MRI – Assess for concomitant injuries and presence of open physes – Commonly associated with a lateral meniscus tear Lachman Test ▪ Anterior translation at 20 degrees of knee flexion ▪ Compare both sides ▪ Positive Lachman test graded 1+, 2+ or 3+ with solid end- point noted Initial Treatment ▪ Nonsurgical treatment – Incomplete tears with a normal or near-normal exam – Short period of immobilization and crutches followed by early range of motion and bearing weight as tolerated ▪ Surgical treatment – Complete tears in an active patient Growth Return to Play Additional Injuries Disturbance Nonsurgical Surgical Tibial Eminence Fractures ▪ Occurs at insertion of ACL – Age 8 to 14 ▪ Concomitant plastic deformation of ACL ▪ Often associated with meniscal entrapment/tearing Treatment ▪ Timing is critical – May attempt closed reduction and immobilization for type II – Needs early operative reduction and fixation if unable to satisfactorily reduce ▪ Surgical management – Open or arthroscopic – Sutures or screws ▪ ↑↑ Risk of stiffness – Associated with ↑ surgery length ↑ time to surgery – Early mobilization is critical Collateral Ligament Sprains ▪ Non-contact Varus/Valgus Force ▪ Beware of physeal injury in skeletally immature patient ▪ Pain/laxity with varus/vulgus stress at 0/30 degrees of knee flexion ▪ Point tenderness/swelling/ecchymosis – Effusion may not be present ▪ Plain knee radiographs to rule out fracture ▪ Knee immobilizer or hinged brace and WBAT ▪ Surgery rarely indicated ▪ Require 4-6 weeks prior to return to sports Meniscus Tears ▪ Non-contact Twisting Injury ▪ Effusion and limited ROM ▪ May report feelings of clicking or locking ▪ Medial or lateral joint line tenderness – Made worse by flexion and internal/external rotation ▪ Uncommon in a skeletally immature patient with normal meniscal morphology ▪ Tears in younger patients usually associated with a discoid type meniscus morphology ▪ Most will require surgery with repair vs. partial resection for symptom relief Discoid Meniscus ▪ Congenital anomaly – Abnormal size, shape